Transplantation Immunology.pdf - E-Lib FK UWKS

Status of Liver Transplantation 33
A recent report on HCV-infected liver transplant recipients estimated the
risk of developing recurrent cirrhosis to be as high as 44% at 5 yr posttransplant
(14). Berenguer et al. reported data from the UNOS registry demonstrating that
5-yr graft survival in recipients transplanted for hepatitis C was 56.8%, the
worst of all indications with the exception of malignancy (14). Antiviral agents
(interferon, including pegylated interferons, ribavarin, or combinations) have
a low rate of success because of poor patient tolerance, side effects, or a limited
and/or transient response.
In contrast, significant progress has been achieved in the outcome of hepatitis
B virus (HBV)-infected liver recipients with the use of current HBV antiviral
agents. Han and colleagues reported negative hepatitis B surface antigen
serology in 98.3% of patients after transplantation using intramuscular antihepatitis
B immunoglobulin and lamivudine (15).
5. Tumors
Another major demographic shift is the reduction in the proportion of patients
transplanted for primary liver cancer. This diagnosis is clearly associated with
poor outcome because of recurrent disease. In the European Liver Transplant
Registry (ELTR) data, the 1-, 5-, and 9-yr patient survivals for patients with
cirrhosis (79, 69, and 62%) are significantly better than for patients treated for
primary liver cancer (67, 40, and 26%). With improvements in imaging technology,
as well as the adoption of defined selection policies, the proportion of
livers being transplanted for cancer is falling.
6. Retransplantation
In recent years there has been a significant decrease in the number of retransplants
performed. This reflects improvements in every step of the transplant
process, including choice of donors, preservation fluids, surgical techniques,
and, perhaps most important, postoperative recipient management and immunosuppressive
protocols. This issue was addressed by Clemente et al. (16) in a
large retrospective analysis covering more than a decade. They demonstrated
a shift in the major cause of retransplantation from chronic rejection to primary
graft failure, with 5-yr actuarial survival rates dependent on the cause
of graft failure (45.5% for chronic rejection and 19.4% for primary failure)
(16). Graft loss caused by rejection is now uncommon after liver trans-plantation.
The incidence of chronic rejection in 1048 liver recipients followed for
a mean period of more than 6 yr was only 3% (17). In a randomized trial
comparing cyclosporine with tacrolimus after liver transplantation (the
Tacrolimus vs Microemulsified Ciclosporin [TMC] study), the incidence of
chronic rejection was only 0.3% in the tacrolimus group (18). Another study
concluded that chronic rejection does not occur in the pediatric liver recipi-